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Special Articles

AUTOMATION IN CLINICAL BIOCHEMISTRY

A. L. TÁRNOKY.

MUCH of the work performed in hospital laboratoriesrequires attention to individual detail and an eye for theunexpected. Some of the routine operations, however,are well suited to mechanical processing: the ’ Histokine ’has cut delays and drudgery in the histology department,and automatic red-cell counters are appearing in

hxmatology laboratories. Chemical analysis by automaticmeans is well known in industry, and its adaptation tohospital conditions could be expected. The simplest stepin automation is the mechanical delivery of measuredvolumes of liquid, and most visitors to laboratories haveseen the home-made automatic pipettes based on syringesor gin-dispensers which have served as prototypes for anumber of commercial models of variable predictability.More recently, complete mechanical procedures for bio-chemical analysis have been devised by Skeggs,l and acommercially made version of his apparatus has been inservice for up to two years in several hospitals. Theprototype of a similar instrument has since been described

by Jonnard .2 The appearance of such a machine breaks new ground,

even though its main, and surprising, feature is an

adherence to traditional methods of analysis. As its mainnew departure the method eliminates measurements ofvolume (except in the preparation of reagents), replacingit by a continuous process in parallel channels, in whichstreams of reagents and blood travel at identical speedsand react with each other by diffusing across a semi-

permeable membrane separating the channels. Specimensare loaded by hand and are drawn through the apparatus,which consists of a dialyser, a heating-bath for some ofthe analyses, and a continuous-recording photoelectriccolorimeter. The method of analysis is always colorimetric,and the results on the chart are worked out by theoperator. The machine is therefore a straightforwardmechanised version of what is done by hand in

biochemistry departments.Though this automatic analyser may only be the first

of its kind, its existence is bound to affect hospitallaboratories and even the development of clinical bio-chemistry as a subject. Its main effects are likely to be these:

1. Since automatic operations are more easily controlledthan manual ones, methods requiring strictly standardisedconditions can now be introduced into routine practice; thediacetyl-monoxime method of estimating blood-urea,3 whichtends to be erratic when carried out by hand, now serves as asatisfactory automatic procedure. The way in which a majorpiece of equipment influences thinking is of course not withoutits dangers, and biochemists may come to think of newmethods in terms of the automatic analyser they already have,even where a colorimetric method would not otherwise be themethod of choice.

2. Automatic methods give more accurate as well as morereliable results, the latter being the more important. Thoughexperimental accuracy need not be refined much beyondclinical requirements, manual methods sometimes fall shorteven of this standard; but the occasional stray results are farmore disturbing, especially since clinical staff cannot be

expected always to bear in mind that a biochemical result

represents a probability within two standard deviations. Strayresults can often be traced to the distracting conditions of abusy hospital laboratory, to which the machine is not sensitive.

1. Skeggs, L. T., Jr. Amer. J. clin. Path. 1957, 28, 311.2. Jonnard, R. Ann. N. Y. Acad. Sci. 1960, 87, 669.3. Fearon, W. R. Biochem. J. 1939, 33, 902.

3. Most laboratories will want to keep the machine or, =tight schedule, switching from one method to another at::;times of the day. It will not be convenient to stop a deal with an urgent request out of turn, or to start the macci-.:in an emergency at night. To retain the present man:methods would defeat some of the objects of automatic

analysis; the need is for a set of emergency procedure-,,accurate enough for immediate purposes. These new bedsidemethods are likely to be of the commercial tablet or matchsttype. The blood sample can then be saved, and the exresult obtained at leisure.

4. The fifteen mechanical methods available at presentaccount for the bulk of routine work. Since running themachine requires only unskilled machine-minding with someexpert supervision, automation will release skilled workers tointroduce estimations now restricted to specialist centres. Itmay ultimately affect laboratory staffing, accentuate existingdifferences between biochemical technicians training in smalllaboratories and those in large mechanised departments, andnecessitate radical changes in their examination syllabus.

5. Economic consequences are also to be expected. Theinitial cost of the apparatus, the turnover required for savingon running costs, and the increased reserve capacity of themachine (the marginal cost of adding more specimens to abatch is slight, whereas a technician’s efficiency will declinebeyond an optimal batch size 4) mean that departmentsinstalling automatic analysers already have large work loads orexpect to have them. Automation will make these largelaboratories more efficient and will accentuate the differencebetween large and small centres; it will be useless to plan smallbiochemistry laboratories in the knowledge of technical

developments, and then to argue that automation in thesesmall laboratories is not economically feasible. A number ofsimilar points arise : for instance it will be wasteful to keep atechnician stationed in the diabetic clinic to do blood-sugartests manually if better results can be got more quickly, sothat the relative siting of laboratories and outpatient depart-ments will require renewed attention when our new hospitalsare planned. A. L. TARNOKY.

4. Verschure, J. C. M. Scand. J. clin. Lab. Invest. 1957, 10, suppl.

POLIOMYELITIS VACCINES

THE Minister of Health, in answer to a question in theHouse of Commons on April 12, indicated that inactivatedpoliomyelitis vaccine would, for the present, remain thetype to be provided for the official vaccination scheme.This course was advised by the joint subcommittee ofthe English and Scottish Medical Advisory Committeeswhich has throughout advised the Health Ministers. Thesubcommittee has also advised that fourth doses should beoffered to children of primary-school age-that is, fromthe age of five up to eleven years-who have already hadthree doses.A British attenuated vaccine for administration by

mouth has been produced, but the subcommittee does notadvise its use in the normal vaccination scheme yet.Further studies of the ability of this vaccine to colonise the !intestine and uniformly lead to the production of mu-

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bodies are in progress. There are, however, circum-stances in which the ability which attenuated virus strainsare believed to possess, to colonise the intestine and SOblock the spread of wild virus in the community mightgive advantages in controlling a developing local outbreak.It is not certain that such an effect could be obtained underBritish conditions with a population already well immu-nised. The prospect of complete success in this respect ,:

depends on feeding live vaccine to the bulk of the haspopulation within a matter of days-a formidable under-taking requiring elaborate organisation and a ready publicresponse.

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The subcommittee advised that there should be areserve of live vaccine. This has been arranged. It will beheld against the possibility of mass use being thoughtdesirable and practicable in an area with a developing localprevalence.The vaccine is composed of the Sabin strains of attenu-

ated virus. It is stored in concentrated form and would bediluted in buffered syrup for oral administration. Vaccineof a virus type different from that of the wild virus causingdisease in the area would be chosen. Distribution locallywould have to be determined by the circumstances of thearea and the outbreak. Medical Officers of Health havebeen informed of the position.

Parliament

THE BUDGET

INTRODUCING his first Budget on April 17, Mr. SELWYNLLOYD, the Chancellor of the Exchequer, said that one of theproblems he faced was the continuing growth in publicexpenditure. Most people no longer held the view imputedto the 19th century that all public expenditure was bad andall private expenditure good. Nowadays, all political partieswere committed to a high and rising level of expenditure oneducation, public health, and other public services. But

though this was accepted, public expenditure must not beallowed to outrun the prospective growth of our resources. Itshould not take too much of our resources from other forms ofeconomic activity where growth was most likely to come. Wemust, therefore, get the priorities as nearly right as we could,both within the public sector and between the public and theprivate sectors. This called for new methods. We needed

increasingly to look at all public expenditure together insteadof piecemeal, and to look at it for a period of years in relationto prospective resources. He had recently set in hand a studyof the whole problem of public expenditure in relation to theprospective future growth of our resources for a period of fiveyears ahead, with the object of seeing how we could best keeppublic expenditure in future years in proper relationship to thegrowth of our national product. He believed that there weresavings to be made by so-called administrative economies, andthat if those, at all levels, who have charge of the spending ofpublic money would bring to the task the same prudence theyapply to their own financial affairs the results would be worthwhile.

Mr. Lloyd’s fiscal proposals for 1961-62 include a modestincrease in the tax allowance for National Insurance contribu-tions (from E15 to £18) in recognition of the changes whichthe graduated National Insurance scheme will bring. In viewof the higher National Insurance retirement pensions nowpayable he also proposed to increase by £20 the income limitfor the dependent-relative allowance. The increase in motor-vehicle duties excludes ambulance and invalid carriages whichare at present exempt.More substantial changes deal with surtax. Earned income

allowances will become deductible in computing income forsurtax, and the tax will begin at £4000 instead of £2000. Takentogether these two proposals mean that surtax will not bepayable on earned income until it reaches £5000 (or more fortaxpayers with children), but the new rates will not affect theameunts due in January, 1962, on income earned during1960-61.

Justifying his surtax proposals, Mr. Lloyd said that in themodem world the work of the manager, the scientist, the tech-nologist was of increasing importance to the community. Hewished to ensure that surtax did not act as a disincentive tothose who had positions of responsibility in our industries andelsewhere in our national life.

As part of the Budget, Mr. Lloyd also asks for power tointroduce during the year a pay-roll tax of up to 4s. per em-ployee per week. This would act as an incentive to economyin the use of man-power and to investment in labour-savingequipment. As a temporary expedient he would collect thissurcharge by attaching it to the employer’s share of theNational Insurance stamp. But he recognised the risk of con-fusion between this surcharge and the contribution, whichmight undermine the contributory principle on which NationalInsurance was based, and he would continue to examine othermethods of levying it.

Mr. HUGH GAITSKELL, opening the debate as leader of theOpposition, suggested that the proposed pay-roll tax wouldfall heavily on concerns which use a large amount of labour;which, though he did not mention it, would seem to includethe National Health Service. He did, however, mention theservice in his criticism of the surtax adjustments. The Chan-cellor, Mr. Gaitskell pointed out, had taken in a full year aboutE60 million off surtax, which was very close to the amount hehad imposed in the increased health service charges and con-tributions. He continued, " What happens is that a man onE10 a week is to pay 10d. a week more in contributions and isto pay more when he goes to the doctor for his prescription,and the man .earning S2000-S5000 a year is to be substantiallybetter off ".

Criminal Justice Bill

AT the report stage of this Bill in the House of Commons on

April 11, Sir THOMAS MOORE sought to introduce a new clausegiving the courts power to pass a sentence of corporal punish-ment on young male offenders convicted of a second (orsubsequent) crime of violence. Mr. R. A. BUTLER, the HomeSecretary, resisted the proposal. Though he agreed that therewas anxiety in the country about the present state of crime,he did not believe that corporal punishment was the rightremedy. The whole object of the Bill was to provide alternativemethods of dealing with young offenders. One of the most

important would be detention centres, where, he assured theHouse, the regime was strict. He admitted that till recentlyprogress in building these centres had been too slow, andwhen the Bill was first introduced there were only a few.There were now 7, of which 3 had been opened since thesecond reading. 6 more centres were planned, 2 of whichwould be opened this year. In all there would be 13, whichwas 1 more than originally promised.

Sir REGINALD MANNINGHAM-BULLER, the Attorney-General,said that, as the rejection of the clause was a Governmentdecision, there could be no free vote; but 67 Conservativemembers voted for it. With the help of Opposition membersit was, however, defeated by 259 to 67 votes after a debate ofover five hours.

Mr. J. E. MACCOLL moved the insertion of a new clauseraising the age-limit for the death penalty from 18 to 21.But Mr. BUTLER said that the Government were unable to

accept the clause because they felt that it was too soon todraw conclusions about the result of the Homicide Act of 1957and because of the great increase in crimes of violence com-mitted by people aged between 17 and 21. To raise the

age-limit now might give some young people the idea thatcapital murder was not a heinous and terrible crime. Theclause was rejected by 229 votes to 144.

Mr. Butler moved the deletion of an amendment made incommittee providing that children under 16 should not besent to borstals until adequate remand centres were available.He sympathised with the motive behind the amendment,which was to prevent children being sent to prison on remand.But as it stood now, the Bill would prevent magistrates fromsending a child to a borstal when they considered that themost suitable form of training, and he thought that issue wasmore important. He agreed that owing to the big drive forbuilding prisons and detention centres too little progress had